Politicized health emergencies and violent resistance against healthcare responders
| Published date | 01 July 2024 |
| DOI | http://doi.org/10.1177/00223433231158144 |
| Author | Melanie Sauter |
| Date | 01 July 2024 |
https://doi.org/10.1177/00223433231158144
Journal of Peace Research
2024, Vol. 61(4) 513 –528
© The Author(s) 2023
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DOI: 10.1177/00223433231158144
journals.sagepub.com/home/jpr
1225162JPR0010.1177/00223433231158144Journal of Peace ResearchSauter
research-article2023
Regular Article
Politicized health emergencies and violent
resistance against healthcare responders
Melanie Sauter
Department of Political Science, University of Oslo
Abstract
2019 has been the most violent year on record for health workers in the Democratic Republic of the Congo. Attacks
on healthcare coincided with the first-ever Ebola outbreak in an active conflict zone. Many of the attacks on the
Ebola response were perpetrated by civilians who intended to disrupt the response, which in turn contributed to the
spread of the virus. Why would communities attack the very people trying to protect them from disease? This mixed-
method study examines the case of violence against Ebola responders during the Democratic Republic of the Congo’s
tenth Ebola outbreak from 2018 to 2020. First, an ‘explaining-outcome’ process tracing reconstructs key events that
led to the violent resistance of the population. I find that – contrary to popular belief – distrust alone was not the
main driver. Rather, I argue that the politicization of the response provoked violent popular resistance. Second, an
interrupted time-series model shows that the exclusion of three regions from the presidential election due to Ebola
led to a significant increase in attacks on Ebola responders. The analysis demonstrates that the behavior of healthcare
responders has limited ability to build trust when other political dynamics are at work. The article illustrates how
combining process tracing with quantitative causal inference methods enables the simultaneous inquiry of cause,
mechanism, and effect.
Keywords
Democratic Republic of the Congo, distrust, Ebola, political exclusion, popular resistance, violence against
healthcare
The paradox of popular violence against
healthcare
2019 has been the most violent year on record for health
workers in the Democratic Republic of the Congo
(DRC) (WHO, 2020). Attacks on healthcare coincided
with the first-ever Ebola outbreak in an active conflict
zone. Many attacks against the Ebola response were per-
petrated by civilians and aimed at disrupting the
response, which in turn contributed to the spread of the
virus (Wells et al., 2019). For example, on 15 September
2019, civilians reportedly set four medical facilities and
18 houses for Ebola responders on fire. The local com-
munity accused the Ebola responders of killing people
and disguising their deaths as resulting from Ebola so
that they could continue to receive humanitarian funds
(Insecurity Insight, 2019).
Why would communities attack the very people who
were trying to protect them from a deadly virus? This
mixed-methodstudy examines the case of violenceagainst
Ebola respondersduring the DRC’s tenth Ebola outbreak
from 2018 to 2020. My main argument is that popular
violent resistance is not solely the result of distrust. Rather,
political exclusion served as a tipping point. In the midst
of the Ebola outbreak, presidential elections were held in
December 2018, with some Ebola-affected provinces
barred from voting. According to the government’s official
statement, it was a health measure to contain the virus.
However, the affected regions were an opposition strong-
hold. After the election exclusion, local elites and media
framed Ebola as a political tool of the government, result-
ing in popular resistance to Ebola responders.
Section two presents an overview of explanations
for popular resistance to healthcare. Health policies that
Corresponding author:
melanie.sauter@stv.uio.no
514 journal of P R 61(4)
target the population unequally can become politicized,
leading to violent resistance. Section three proceeds with
a brief background on the DRC and the tenth Ebola
outbreak. In section four, I begin my search for an expla-
nation with an ‘explaining-outcome’ process tracing.
The ‘shoe-sole’ work reconstructs the sequence of key
events and perceptions during the Ebola response. I find
that, contrary to popular belief, distrust alone was not
the main driver of violence against Ebola responders.
I propose that the politicization of the health emergency
provoked large-scale violent popular resistance. In sec-
tion five, I test the correlation of the novel mechanism in
an interrupted time-series model. The analysis shows
that in the weeks after the election exclusion, violence
against Ebola responders increased sharply. Section six
provides a brief discussion of how the response became
depoliticized over time and gives concluding remarks.
This article makes several contributions. First, it
advances debates about aid and healthcare politicization
by illuminating the link between repressive regimes and
public perceptions. Seemingly neutral health measures
can become politicized when they cannot be distin-
guished from other repressive government measures.
Second, the article adds to the literature on micro-
dynamics of violence by demonstrating when not only
armed groups but also civilians become perpetrators.
Finally, the article shows how combining process tracing
with quantitative causal inference methods allows for the
simultaneous inquiry of cause, mechanism, and effect.
Explanations for violence against healthcare
Popular resistance to healthcare workers during emer-
gencies is not a new phenomenon; it has been observed
during previous epidemics in response to restrictive
healthcare measures. The best-documented cases are
the European cholera outbreak of the 1830s and the
2013/14 West African Ebola epidemic.
During Europe’s first cholera epidemic in the 1830s,
riots raged across the continent, destroying entire cities
and torching healthcare facilities. Doctors and nurses
were required to implement strict government health
measures, such as isolating the sick and quarantining
people. The surveillance-based healthcare strategies
instilled public distrust and fueled the spread of conspira-
cies (Cohn & Kutalek, 2016). People in France believed
that the wealthy elite had ordered doctors to poison the
water supplies of the poor (Evans, 1988). The professio-
nalization of surgeons in Britain increased the demand
for human cadavers. Fear gripped the populace that
doctors were conspiring against the poor to preserve their
bodies for experiments (Tognotti, 2013).
During the 2013/14 Ebola epidemic in West Africa,
violent mobs protested and attacked aid workers, burn-
ing down healthcare facilities and destroying provisional
treatment facilities. Due to the risk of infection, the
dignified burial of disease victims was a source of con-
tention. Fears that the state had poisoned or buried the
patients alive provoked riots and protests, including
attacks on health workers and the burning of treatment
facilities (Cohn & Kutalek, 2016).
These previous resistance movements demonstrate
that government-imposed healthcare strategies, even
when well-intended, can become politicized when they
disproportionately affect certain groups. The riots were
sparked by distrust of the government’s intentions
behind the healthcare measures, not by the epidemic
itself.
Literature on violence against aid workers during
humanitarian emergencies looks at the individual beha-
vior of humanitarians (Fast, 2014), criminal violence
driven by economic motivations (Buchanan & Muggah,
2005; Naylor, 1997) and political motivations of orga-
nized armed groups (Anderson, 1999; Lischer, 2006;
Narang & Stanton, 2017; Sauter, 2017; Stoddard, Har-
mer & DiDomenico, 2009). The explanations are
mostly based on structural factors that could explain why
the phenomenon occurs more frequently in some con-
texts than in others. However, they do not specifically
address violence against healthcare or the circumstances
in which civilians are the prevalent perpetrators. In con-
trast, the literature on violence against healthcare is dri-
ven by medical and health researchers who analyze the
lived experiences of healthcare personnel. The majority
of these studies identified frustrations and misunder-
standing with medical services as the causes of this vio-
lence (Haar et al., 2021; ICRC, 2020). These studies
cannot explain why violence against healthcare is more
widespread in some cases.
An epidemic can be used to violently manifest state
power. Health security, defined as protection from
threats to health, is often blurred with national security,
defined as threats to sovereign power (Benton, 2017:
32). Securitization is a discursive process that declares a
specific issue to be an existential threat. Securitizing an
issue gives a government the authority to take emergency
measures that may violate legal constraints and demo-
cratic principles (Buzan, Wæver & De Wilde, 1998).
The United Nations (UN) Security Council Resolu-
tion 1308 on HIV/AIDS, passed in 2000, was the first
UN document to frame a health issue as a threat to
2journal of PEACE RESEARCH XX(X)
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